Vol. 40 No. 2 August 2010
Journal of Pain and Symptom Management
163
Original Article
Evaluation of the FICA Tool for Spiritual
Assessment
Tami Borneman, RN, MSN, CNS, FPCN, Betty Ferrell, RN, PhD, MA, FAAN, FPCN,
and Christina M. Puchalski, MD, MS, FACP
Division of Nursing Research and Education (T.B., B.F.), Department of Population Sciences,
City of Hope, Duarte, California; and The George Washington Institute for Spirituality and Health
(C.M.P.), School of Medicine (C.M.P.), and School of Public Health (C.M.P.), The George Washington
University, Washington, DC, USA
Abstract
Context. The National Consensus Project for Quality Palliative Care includes
spiritual care as one of the eight clinical practice domains. There are very few
standardized spirituality history tools.
Objectives. The purpose of this pilot study was to test the feasibility for the
Faith, Importance and Influence, Community, and Address (FICA) Spiritual
History Tool in clinical settings. Correlates between the FICA qualitative data and
quality of life (QOL) quantitative data also were examined to provide additional
insight into spiritual concerns.
Methods. The framework of the FICA tool includes Faith or belief, Importance of
spirituality, individual’s spiritual Community, and interventions to Address spiritual
needs. Patients with solid tumors were recruited from ambulatory clinics of
a comprehensive cancer center. Items assessing aspects of spirituality within the
Functional Assessment of Cancer Therapy QOL tools were used, and all patients
were assessed using the FICA. The sample (n ¼ 76) had a mean age of 57, and
almost half were of diverse religions.
Results. Most patients rated faith or belief as very important in their lives (mean
8.4; 0e10 scale). FICA quantitative ratings and qualitative comments were closely
correlated with items from the QOL tools assessing aspects of spirituality.
Conclusion. Findings suggest that the FICA tool is a feasible tool for clinical
assessment of spirituality. Addressing spiritual needs and concerns in clinical
settings is critical in enhancing QOL. Additional use and evaluation by clinicians
of the FICA Spiritual Assessment Tool in usual practice settings are
needed. J Pain Symptom Manage 2010;40:163e173. Ó 2010 U.S. Cancer Pain
Relief Committee. Published by Elsevier Inc. All rights reserved.
Key Words
Spiritual care, FICA assessment tool, clinical evaluation
Address correspondence to: Betty Ferrell, RN, PhD, MA,
FAAN, FPCN, Division of Nursing Research and Education, Department of Population Sciences, City of
Ó 2010 U.S. Cancer Pain Relief Committee
Published by Elsevier Inc. All rights reserved.
Hope, 1500 East Duarte Road, Duarte, CA 91010,
USA. E-mail: [email protected]
Accepted for publication: January 19, 2010.
0885-3924/$esee front matter
doi:10.1016/j.jpainsymman.2009.12.019
164
Borneman et al.
Introduction
Over the past 15 years, there has been growing interest in and attention to spiritual care as
a dimension of palliative care and the association of spiritual or religious beliefs and health
care outcomes such as quality of life (QOL),1
will to live,2,3 depression,4 and coping.5 Implicit in the need to provide measurable patient outcomes is the need to demonstrate
worth of specific services.6e8 The National
Consensus Project for Quality Palliative Care
(NCP) and the National Quality Forum determined spirituality to be an essential element of
care as described in Domain 5 of the NCP
Guidelines: Spiritual, Existential and Religious
Concerns.9,10 Because spiritual care is important to the patient’s health and a necessary domain of quality care, this aspect of care also
will be essential to demonstrate efficiency
and effectiveness of care. This presents a challenge to the whole ethos of spiritual care ‘‘because as spirituality becomes rationalized and
reduced to make it manageable, it begins to
lose the subjective and specific human experience, which makes it significant.’’6
In implementing other aspects of palliative
care, there are clinical instruments for assessment of those domains, such as a social history
or symptom assessments. Thus, one aspect of
spiritual care often prioritized is the need for
a systematic approach to spiritual history.
This approach would allow the patient to
share his/her spirituality or religion and
would provide a means for obtaining measurable outcomes. A good spiritual history involves more than a simple list of organized
religions. A spiritual history requires a broader
inquiry of the patient’s beliefs and values, their
ability to find meaning and hope in the midst
of suffering, recognition of the role of spirituality or religion in the patient’s life, the
importance of ritual, identification of faith
traditions, and evaluation of the impact of
the patient’s current illness on spiritual wellbeing.
Patients facing a serious illness or the end of
life may experience numerous spiritual concerns. Some of the most common include
an inability to find meaning and purpose,
hopelessness, anger at God, asking ‘‘Why?’’
and struggling with a will to live.5,11e15 Palliative care clinicians need to be skilled in
Vol. 40 No. 2 August 2010
communication to assess, listen, and support
patients and families through the process of illness, death, and bereavement. Additionally,
the confidentiality implicit in the patientprovider relationship places the clinician in
a privileged status, whereby the patient may
feel safe in discussing spiritual issues.16e20
Several articles have noted the ethical
boundaries in discussing spiritual issues with
patients, including respect, collaboration with
spiritual care providers such as board-certified
chaplains, and including a prohibition on
proselytizing.19,21,22
A recent study by Phelps et al.23 (n ¼ 345)
reported that most patients with advanced cancer (78.8%) relied on their religion to help
them cope with their illness. A greater use of
positive religious coping was associated with receiving intense life-prolonging treatment, such
as mechanical ventilation or resuscitation, during the last week of life.
Past studies have shown that 41%e94% of
patients and family caregivers want their clinicians to address their spiritual concerns.24e28
In a study conducted by Ehman et al.,29 177
adult ambulatory patients with pulmonary disease completed an 18-item self-administered
survey in which the key question asked patients
to respond to the statement ‘‘If I become
gravely ill, then I would like my doctor to ask
whether I have spiritual or religious beliefs
that would influence my medical decisions.’’
Sixty-six percent of the participants responded
that they would like their physicians to ask
whether they have spiritual or religious beliefs
that would influence their medical decisions if
they became seriously ill.
McCord et al.30 administered a questionnaire to 921 patients in the waiting rooms of
four urban family practice residency training
sites and one suburban private group practice
in the Midwest. The goal was to determine
when patients think it is appropriate for physicians to inquire about spiritual beliefs, reasons
why they would like for this to happen, and
what they want their physician to do with
the information. Eighty-three percent wanted
their physicians to ask about spiritual beliefs
in some situations, 87% reported that the
most important reason for wanting to discuss
spirituality was for physician-patient understanding, 67% thought that information about
Vol. 40 No. 2 August 2010
Evaluation of the FICA Tool for Spiritual Assessment
their spiritual beliefs would affect the doctor’s
ability to provide realistic hope, provide medical advice (66%), and change medical treatment (62%).
Balboni et al.17 reported that 88% (n ¼ 230)
of advanced cancer patients considered religion
to be at least somewhat important. However, almost half (47%) reported unmet spiritual needs
by the religious community and 72% by the
medical system. QOL was significantly associated with spiritual support from the community
or medical system as was religiousness and wanting all treatment to extend life.
These studies provide examples of the paramount need for a spiritual history tool that is
effective, comprehensive, and user friendly
within busy clinical time constraints to facilitate health care professionals in providing
care, which includes spirituality as a component of patient care.
Background of the FICA Spiritual History
An initial step in addressing spirituality in
the clinical setting is to define the concept.
‘‘The absence of a clear definition of spirituality.’’ is a commonly repeated statement in the
health care literature. There is in the literature
recognition of the distinction between spirituality and religion.21,24,31e34 A definition that is
derived from a recent consensus conference is:
Spirituality is the aspect of humanity that refers to the way individuals seek and express
meaning and purpose, and the way they
experience their connectedness to the
moment, to self, to others, to nature and
to the significant or sacred.35
A spiritual history is a set of questions designed to invite patients to share their religious
or spiritual beliefs to help identify spiritual issues. It is to be patient centered and guided
by the extent to which the patient chooses to
disclose his/her spiritual needs. There are several tools available for taking a spiritual history,
including the Systems of Belief Inventory
(15R),36 Brief Measure of Religious Coping,37
Functional Assessment of Chronic Illness
TherapydSpiritual Well-Being,38,39 SPIRITual
History,40 FICA Spiritual History,8 and
HOPE.41 Some of these instruments are intended primarily for research, whereas the
others have been used primarily in the clinical
setting for nonchaplain clinicians. These later
165
clinical tools include FICA, SPIRIT, and
HOPE, each of which has had minimal psychometric evaluation.
The FICA Spiritual History Tool, created
by Dr. Christina Puchalski in 1996, in collaboration with three primary care physicians
(Drs. Daniel Sulmasy, Joan Teno, and Dale
Matthews) provides a way for the clinician to
efficiently integrate the open-ended questions
into a standard medical history and can be
used by health care professionals (Fig. 1).
The tool was developed in a consensus process,
whereby the collaborators reviewed questions
Dr. Puchalski used as a spiritual history in
teaching medical students. They determined
the key elements of what a physician or clinician would need to know about a patient’s spiritual beliefs in the clinical setting. The tool has
since been modified based on anecdotal feedback received from users of the tool. The FICA
tool is based on four domains of spiritual
assessment: the presence of Faith, belief, or
meaning; the Importance of spirituality on an
individual’s life and the influence that belief
system or values has on the person’s health
care decision making; the individual’s spiritual
Community; and interventions to Address spiritual needs.8
Methods
The aim of this descriptive pilot study was to
provide preliminary clinical evaluation of the
feasibility and usefulness of the FICA Spiritual
Assessment Tool. The study was approved by
the institutional review board of the City of
Hope.
Seventy-six patients with solid tumors
(breast, lung, colon, and prostate) participating in a larger National Cancer Institutefunded study (Reducing Barriers to Pain and
Fatigue Management, R01-CA115323-4; B. Ferrell, principal investigator) in the medical oncology ambulatory clinics of a comprehensive
cancer center were asked if they would be willing to answer questions regarding their spirituality. Their responses were written on the
survey or recorded by the nurse in writing. Eligibility criteria were based on the larger study
and included 1) cancer diagnosis more than
one month, 2) age older than 18 years, and
3) English speaking. Patients were asked the
FICA interview questions by the research
166
Borneman et al.
Vol. 40 No. 2 August 2010
FICA Tool
F – Faith, Belief, Meaning
Religious/Religiosity – Pertains to one’s beliefs, behaviors, values,
rules for conduct, and rituals associated with a specific religious
tradition or denomination (O’Brien, 1999).
Spirituality – Generally, an “individual’s attitude and beliefs related
to transcendence (God) or to the nonmaterial forces of life and of
nature…the dimension of a person that is concerned with ultimate
ends and values” and meaning (O’Brien, 1982, p. 88; Taylor, 2006).
Do you consider yourself spiritual or
religious?
Do you have spiritual beliefs that help
you cope with stress?
What gives your life meaning?
I – Importance and Influence
What importance does your faith or
belief have in your life?
On a scale of 0 (not important) to 5
(very important), how would you rate
the importance of faith/belief in your
life?
Have your beliefs influenced you in
how you handle stress?
What role do your beliefs play in your
health care decision making?
C – Community
Are you a part of a spiritual or
religious community?
Is this of support to you and how?
Is there a group of people you really
love or who are important to you?
A – Address in Care
We have talked a lot about your spirituality and/or religious
beliefs and how they may or may not be of help to you during
your illness. How can your health care providers best support
your spirituality?
How would you like your health care
provider to use this information about
your spirituality as they care for you?
Fig. 1. FICA Tool.
nurse, generally in a private room in the clinic
setting. Patient demographic data and items
assessing aspects of QOL were derived from
data collected in the parent study using the
City of Hope-QOL Tool, a 45-item multidimensional tool encompassing four domains of
physical, psychological, social, and spiritual
well-being based on the QOL conceptual
Vol. 40 No. 2 August 2010
Evaluation of the FICA Tool for Spiritual Assessment
model developed by the investigators.42 Each
of the 45 items is measured using a 10-point
Likert scale. Internal consistency reliability using Cronbach’s alpha is 0.77e0.89 for the four
subscales and 0.93 overall. Measures of validity
of the generic patient version include content
validity with the Functional Assessment of Cancer Therapy instrument (r ¼ 0.78) and factor
analysis.
Content analysis of the FICA interview questions was used to develop relevant themes or
categories to understand subject’s responses
to the four items of the tool including: Faith,
Importance and Influence, Community, and
Address. Using content analysis methods described by Waltz et al.,43 data were summarized
from each open-ended question, and all data
were entered into preliminary tables by question. Responses were coded by the investigators. All data were reviewed independently by
the three investigators, who assigned codes as
key themes to the content. The investigators
then jointly reviewed the data and created final
summary tables, which were reviewed and discussed. Descriptive analysis of demographic
data was conducted, as well as descriptive and
correlational analysis of the QOL item scores
and FICA.
Results
Demographic Data
Table 1 presents the demographic characteristics of the sample. Patients were predominantly female (77.6%), had a mean age of
58.7, and 50% were ethnic minorities. Most
patients self-identified with a religious preference, with Catholic as most predominant.
Breast cancer was the most common diagnosis.
Importance of Faith or Belief From FICA
Table 2 presents the descriptive data from the
single-item FICA quantitative measure. After
completing the open-ended items of the FICA
survey, subjects were asked ‘‘On a scale of
0 (not important) to 5 (very important), how
would you rate the importance of faith/belief
in your life?’’ These data were transposed for
analysis to a 0e10 scale for comparison to the
QOL items rated on a 0e10 scale.44 The mean
score was 8.4, indicating the subjects’ belief
that spirituality was an important aspect of their
experience of illness.
167
Table 1
Patient Demographics (n ¼ 76)
Variables
Frequency
Percentage
Mean ¼ 58.68
Standard
deviation ¼ 11.88
Range ¼ 25e87
Age
Gender
Female
Male
59
17
77.6
22.4
Race or ethnicity
Caucasian
Hispanic or Latino
Mixed or Other
Asian
African American
Native American
38
26
5
3
2
2
50.0
34.2
6.6
3.9
2.6
2.6
Marital status
Married
Divorced
Widowed
Never married
Living with partner
46
12
9
5
3
60.5
15.8
11.8
6.6
3.9
25
21
19
32.9
27.6
25
Education (highest achieved)
College
High school
Graduate or
professional
<High school
11
14.5
Religion preference
Catholic
Protestant
None
Other
Jewish
Jehovah’s Witness
33
22
10
5
2
2
43.4
28.9
13.2
9.2
2.6
2.6
Diagnosis
Breast
Lung
Ovarian
Colon
Prostate
33
18
11
10
4
43.4
23.7
14.5
13.2
5.3
Quantitative Assessments of Aspects of
Spirituality
To understand the potential relationships
between aspects of spirituality, correlations
were computed among variables. Data for
Table 2
Single-Item Measure of the Importance of
Spirituality
n ¼ 76
Mean
Median
Standard deviation
8.40
10.00
2.83
Scale: 0 ¼ not important to 10 ¼ very important
168
Borneman et al.
this analysis included the items of the Spiritual
Well-Being subscale of the QOL tool (spiritual
activities, change in spirituality, uncertainty,
positive life change, purpose, and hopefulness) and the single items of pain, control,
anxiety, depression, and isolation from the
physical and psychological subscales of the
QOL tool. These five variables from the other
subscales were selected from the QOL tools as
aspects of QOL recognized as potentially contributing to spiritual distress. Additionally,
the single-item QOL rating was included. Correlations above r ¼ 0.30 are included in bold in
Table 3 to illustrate variables with moderate or
strong correlation. The most significant information is italicized in Table 3, presenting the
correlation of the FICA quantitative item with
the other variables. It is interesting to note
that the FICA item was moderately correlated
with all items of the Spiritual subscale and
the subscale total, with the exception of the
uncertainty item, and the FICA item was not
associated with the physical symptom items.
Qualitative Analysis of FICA
Tables 4e7 present the summary of themes
from the qualitative analysis of responses to
the FICA tool and representative comments
from this question. Table 4 is a quantitative
summary of key issues in response to the
‘‘FeFaith/Belief/Meaning’’ themes. The most
common responses were related to appreciation of life and family followed by life activities.
Other responses addressed issues such as relationship with God and many other broad
aspects of spirituality.
Table 5 presents the quantitative summary of
the responses to the question of ‘‘IeImportance
and Influence’’ themes and examples of patient
comments regarding the importance and influence of spirituality. Respondents expressed
most often that faith or spirituality was important or very important, and that helped them
cope or control their stress. Interestingly, a
number of subjects stated that their faith or
spirituality was a major factor in their treatment
decision making.
The ‘‘C’’ of the FICA tool asks about patient’s spiritual community. Subjects most often referred to family and friends whose
general support was seen as spiritual support,
or in specific examples, subjects referred to
these supportive others who were praying for
Vol. 40 No. 2 August 2010
them or were part of a church community.
Table 6 presents the quantitative summary
and comments.
The final question ‘‘A’’ of the FICA tool asks
how the patient wishes spirituality should be
addressed in their care. Some subjects expressed beliefs that health care providers
should focus on the ‘‘medical aspects’’ of
care and should not focus on spiritual needs.
Others did feel that attention to spiritual
care was supportive, and a chaplain should
be available (Table 7).
Discussion
This study was intended to advance the
growing interest in spiritual care as an essential
domain of palliative care. Subjects were able to
complete the FICA tool and identify those aspects of their lives that provided greatest spiritual support. Patents also were able to
communicate their beliefs when spiritual care
needs were met and they did not need attention from professionals, which is helpful as
clinical settings attempt to use resources most
efficiently.
This sample was ethnically diverse, with 50%
being non-Caucasian. Future studies also
should seek to include more diverse religious
preferences and those with no religious affiliation. From a methodological perspective, the
investigators believe that having both qualitative and quantitative measures of spirituality
was very beneficial and would be important
in future research. The authors also recognize
that further evaluation of the FICA tool should
be done within the clinical practice setting by
clinicians to further establish feasibility of spiritual history in practice.
Quantitative data did show that the FICA
tool was able to assess several dimensions of
spirituality based on correlation with the spirituality indicators in the City of Hope-QOL
tool, specifically spiritual activities, change in
spirituality, positive life change, purpose, and
hopefulness. This latter finding is not surprising as, anecdotally, clinicians find that inquiry
into spiritual beliefs of patients opens the door
to conversations about many issues the patients may be experiencing such as depression
or anxiety. McCord et al.30 also found that
patients felt an increased sense of trust with
Activities
Change
Uncertainty
Positive
Purpose
Hopeful
Pain
QOL
Control
Anxiety
Depression
Isolation
Spiritual
Subscale
0.617
0.459
0.173
0.421
0.422
0.299
0.173
0.065
0.069
0.043
0.045
0.230
0.535
0.433
0.104
0.457
0.412
0.346
0.237
0.139
0.019
0.069
0.063
0.169
0.545
0.190
0.508
0.352
0.225
0.131
0.030
0.009
0.043
0.085
0.074
0.405
0.114
0.25
0.186
0.007
0.272
0.100
0.503
0.465
0.145
0.014
0.391
0.268
0.188
0.160
0.016
0.013
0.044
0.078
0.306
0.650
0.129
0.223
0.177
0.043
0.005
0.012
0.568
0.046
0.321
0.392
0.115
2.35
0.136
0.369
0.298
0.183
0.186
0.122
0.311
0.208
0.458
0.249
0.097
0.346
0.115
0.336
0.304
0.454
0.024
0.702
0.376
0.063
0.560
0.037
0.066
0.467
Key: actual items used
Religion ¼ How important to you is your participation in religious activities such as praying, going to church?
Activities ¼ How important to you are other spiritual activities such as meditation?
Change ¼ How much has your spiritual life changed as a result of cancer diagnosis?
Uncertainty ¼ How much uncertainty do you feel about your future?
Positive ¼ To what extent has your illness made positive changes in your life?
Purpose ¼ Do you sense a purpose/mission for your life or a reason for being alive?
Hopeful ¼ How hopeful do you feel?
Pain ¼ To what extent are general aches or pain a problem for you?
QOL ¼ How good is your quality of life?
Control ¼ Do you feel like you are in control of things in your life?
Anxiety ¼ How much anxiety do you have?
Depression ¼ How much depression do you have?
Isolation ¼ How much isolation do you feel is caused by your illness/treatment?
FICA Quantitative ¼ How would you rate the importance of faith/belief in your life?
Evaluation of the FICA Tool for Spiritual Assessment
Activities
Change
Uncertainty
Positive
Purpose
Hopeful
Pain
QOL
Control
Anxiety
Depression
Isolation
FICA quantitative
Religion
Vol. 40 No. 2 August 2010
Table 3
Inter-Item Correlation Matrix of Items From QOL Tool and FICA Quantitative Rating
169
170
Borneman et al.
Vol. 40 No. 2 August 2010
Table 4
Quantitative Summary of Key Issues in Response to the ‘‘FeFaith/Belief/Meaning’’ Themesa
n ¼ 73
Faith/Belief/Meaning Themes
Appreciation of life and family
Life activities (work sense of purpose, friends, accomplishments, self-sufficiency,
and productivity)
Faith or hope in healing or in a higher being
Relationship with God or serving God
Appreciation for everything in life
Reading Bible
No identified faith tradition or agnostic
Positive state of mind
47
31
18
12
7
5
5
5
Examples
FICA001: Yes, I consider myself Catholic. I seek God almost every single day. I thank him for another day in life and. for
opening my eyes to everything that’s around medthe flowers, the trees, the beauty of things, the beauty of people. And, uh, I’m
happy that I have the faith and that I have a lot of people that have been praying for me and my recovery. Oh, my family. I just
love my family. I want to see my grandchildren grow up and enjoy life, you know, with my husband, get old with him.
FICA004: I guess spiritual in some way, not formally religious because I was raised Catholic but I don’t practice anymore. But I
did appreciate the chaplain coming to see me. There’s something about that that just makes you feeldjust makes you feel good,
so I did appreciate that. You know, everybody says, ‘‘Our thoughts and prayers are with you.’’ I guess I appreciate that. I have a lot
of friends who are religious and say that prayer helps them and I say, ‘‘Well, I hope your prayers help me.’’
FICA007: Oh religious, well both. But spiritual kind of has a bad connotation, lots of people feel spiritual is a cop out. People
can go to church regularly and be religious and not have a spiritual life so I would have to say both. God’s in control and he is
using me in some way. There have been a lot of people in our church with cancer. many of whom have died, but have been
content. with their disease and situation and trusting God. the ones that have died they’re like a great cloud of witnesses to
me. They’re my heroes. I got people in Turkana, Japan, Italy, Africa praying for me. I love the people in my church.I love
being at my church. I have been blessed with a real good wife, who when she came to Christ uh just showed a difference. she
wasn’t pushy or anything but she was there for me.
FICA034: I consider myself a spiritual person not a religious person. We don’t attend a church. But I do believe in a Higher
Being and I have had to come to terms with my own mortality. as far as I feel there is a God. there’s some plan to all of this
and I have been given something that’s difficult to get through, but I don’t believe that I’ve been given anything more difficult
than I can do. I do a lot of visualization, to maintain my level of anti-nausea. I call it ‘‘going to my zero place’’.that helps my
spiritual being as well.
FICA036: I am a Christian. With God nothing is impossible. He has moved mountains for me. One thing I have realized is that
it’s not about me. I’m here to give Him the glory. I meditate on God’s word. I believe that God is God and he is in control.
I stand on His words. God is the whole source of my life. I just realize I am here to love Him, to serve Him, to serve my family, to
serve others. It’s just a neat time.
a
‘‘Do you consider yourself spiritual or religious?’’ or ‘‘Do you have spiritual beliefs that help you cope with stress?’’ If the patient responds ‘‘no,’’
the physician might ask, ‘‘What gives your life meaning?’’
physicians who conducted a spiritual history. It
may be that having that increased sense of
trust enables patients to feel more comfortable
about sharing issues like depression.
The spiritual history tool FICA is also able to
provide a framework for clinicians to open the
door to discussion about those things that are
of meaning to patients, such as family, work,
and faith. It also provides information about
things that are supportive to patients such as
spiritual communities or spiritual sources of
strength. FICA also can give information on
spiritual beliefs affecting health care decision
making. As seen from the data, all these factors
are important in a patient’s health care outcomes, including coping. This study provides
a tool that can help elicit important clinical
information.
Many patients surveyed in this study felt
that they wanted their spirituality to be
integrated in some way in the clinical plan,
but many felt that these needs were met outside of the health care system. Asking about
spirituality may be most important as an aspect of respectful care for people during illness, enhancing the patient and provider
relationship rather than necessarily impacting
the treatment plan.
Summary
This study attempted to evaluate the FICA
tool, and the findings lend support to the
importance of spiritual care as an aspect of
quality patient care and use of the FICA
tool as a valuable instrument for clinical assessment. Responses to the FICA questions
reveal the depth and breadth of spirituality,
and the many opportunities for addressing
Vol. 40 No. 2 August 2010
Evaluation of the FICA Tool for Spiritual Assessment
171
Table 5
Quantitative Summary of the Responses to the Question of ‘‘IeImportance and Influence’’ Themesa
Importance and Influence Theme
Faith is important or very important
Faith helps control stress
Prayer/faith as factor in treatment decisions
Faith equips in preparing/fighting/coping illness
Faith is not important/minimal importance
Faith helps make meaning
God is in control/does not give ‘‘more than we can handle’’
n ¼ 73
56
40
26
10
9
7
5
Examples
FICA001: Without faith and belief there is nothing, so you have to have faith in God that he’s going to help you through this and
also help your family to cope with it. So, having faith and showing that you have faith is very important. I try not to get stressed
any more, because I find that some of these things that bring stress are so tiny compared to. how life is for other people.
FICA002: Well, you know, God’s in control of everything and for me to believe that he lost control when I got cancer is a pretty
odd thing to think. I’ve come to the other side of this cancer and realized that with God even this cancer is a positive thing. Our
relationship, husband and wife, is now closer. We had a good marriage. It was surrounded by our mutual belief in Christ. Stress
is really just a feeling of chaos. When we’re stressed it’s because we don’t think somebody’s in control. And if you understand
that God’s always in control, there’s no reason to be stressed out. I also believe the grace of God is enough to allow us to face
anything.
FICA012: What importance does it have? I think it makes sense of your life. I do believe that things happen for a reason. I do
believe that there are lessons that we’re supposed to learn while we’re here on this earth. I think it helps you get through
situations that seem unfair.
FICA032: My faith is of foremost importance in my life. I’ve attended church continuously since childhood and I was a Sunday
School teacher. Yes, reliance on my belief helps me to deal with stress, which is generally relieved through prayers. When making
health care decisions, I offer prayers of thanksgiving and ask God to aid in my decision making.
FICA036: That is the whole substance of being. Definitely. It calms me. It assures me. It gives me light. It gives me hope. He
directs my path. I would say no because I just know that. Dr. X is a gift from God. I think he anoints doctors and nurses to take
care of the sick. The ultimate healer is God, but he uses his people, medicine.
a
‘‘What importance does your faith or belief have in your life? Have your beliefs influenced you in how you handle stress? What role do your
beliefs play in your health care decision making?’’
patients’ search for meaning, faith, hope, and
relationships at the end of life. There is
a need for extensive additional research to
further evaluate the FICA tool and other
approaches to spiritual assessment and
intervention.
Table 6
Quantitative Summary of Key Issues in Response to the ‘‘CeCommunity’’ Themesa
Community Key Themes
Family/friends
Church
Prayer
Does not identify with a community
n ¼ 73
49
26
8
5
Examples
FICA002: Absolutely. My church is a spiritual community. And also there’s a whole network of people on the internet. I sent out
one letter and about three days later (Name of Spouse) gets a letter. unsigned and it’s anonymous. Somewhere in Florida
someone got that letter from somebody else and sent it to (Name of Spouse) in hopes of helping me. there’s a whole internet
full of people who are part of that.You’ve never met any of these people, but I know they’re there. there’s also (Name of
Spouse) and then I’m part of a church staff. there is also my Bible study group.
FICA005: My church. Yes, people constantly kept in touch either through phone or cards. There are the few times I was able to
get to church. and they mentioned my name under ‘‘Prayers and Concerns’’ when the time came in the worship service to pray
for people and our prayer chains are always praying for me. My family, first and foremost, and my church family, then my friends,
and I have a really close relationship with my work colleagues.
FICA034: Only amongst family and friends. Like I said, we do not go to an organized church, so talking with friends and being
with family members in that respectdthat’s my community.
FICA035: Yes. It’s a support becausedit’s the Catholic Church that I belong to. I’m a Eucharistic Minister, and again it’s the
bonding with the people there and the other ones that have gone through cancer episodes and, you know, the care is theredthe
hug, the handshake. My colleagues at work are like a professional sister group. I have a group that I’m with at church. I have
another group that I’m involved with and that would be our junior high group when we graduated from junior high, so you
know, 40 years ago; we’re still in touch. And my family group is the most important.
FICA036: Yes, ma’am. Yes. I am involved in a Bible study and they pray for me. We just meet each other’s prayer needs there. Oh,
yes. My husband, my children, my precious grandson, my sons-in-law, my parents, sistersdoh, my. This list could go on and on.
I’m very loving.
a
‘‘Are you a part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are
important to you?’’ Communities such as churches, temples, and mosques can serve as strong support systems for some patients.
172
Borneman et al.
Vol. 40 No. 2 August 2010
Table 7
Quantitative Summary of Key Issues in Response to the ‘‘AeAddress in Care’’ Themesa
n ¼ 73
Address in Care Themes
Not necessary
Be supportive
Unsure
Should be addressed
Provider should do what they believe is best
Chaplain availability
Provider should not be involved
15
13
10
8
7
6
5
Examples
FICA001: Um, I’m at loss for words there. Uh, as far as faith goes? The support of the family and friends and religious beliefs that
will help them pull through this. And the doctors, I mean the doctors are very important with helping the patient, you know,
look at things in a positive way.
FICA010: I think it’s to be more open with it. A lot of people don’t like to talk about it. They think that it’s a very private thing.
Some people are embarrassed to bring it up like the health care provider to a patient. they don’t want to bring it up because
they think that they shouldn’t and I think that it’s important to people.
FICA011: Well I would feel that as a health care provider if someone started leaning on me from a religious point of view I would
probably uh fire him or her. Spiritual guidance or whatever. Yeah well I wouldn’t, I wouldn’t look forward to that okay? As far as
my health needs I hope to find good doctors, good health people to guide me you know. But I don’t feel a need for spiritual
guidance or whatever.
FICA034: In my health care? I think here at City of Hope they do, because they have the social work department. I’ve had long
discussions with nurses. I’ve become friends with several of the nurses and staff here, so I think they do address that. They are
willing. The attitude here is that they’re willing to talk with you about more than just your physical well-being, your mental and
social well-being are as important to the staff here. Over the years in the 12 years that I’ve been a patient, I’ve had many
late-night discussions with nurses. If I’m fearful of this or that, they’ll come in and that accessibility is always there.
FICA059: They can remind us patients to utilize and activate own support systems and spiritual practices to honor them in the
hospital.
a
‘‘How should the health care provider address these issues in your health care?’’
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